ABSTRACT Being born extremely preterm is a major contributor to infant mortality and short and long-term morbidities and places a significant burden on the healthcare system. Fortunately, rates of mortality and several major morbidities among the most immature infants have been decreasing. However, it is not known whether the improvement in outcomes has been equally shared among racial groups. Data on utilization of perinatal and postnatal care practices among the different races are also very limited. Additionally, no studies to date have examined whether racial disparities exist in transfer to higher level neonatal intensive care units (NICUs), and if transferred, whether transfers are delayed among preterm births occurring in lower level care facilities. The aims of the proposed study are to examine racial disparities among preterm infants born between 22 and 29 weeks' gestation in: 1) postnatal care practices and an evidence-based practice score reflecting perinatal and postnatal interventions for the care of preterm infants; 2) mortality and major morbidities overall and overtime; 3) transfer and transfer delays to higher level NICUs. To address this, we propose a large-scale observational study using data collected prospectively between 2006 and 2017 from 1,014 hospitals with NICUs located in the U.S. and participating in the Vermont Oxford Network (VON). This data represents 88% of 22 to 29-week births occurring in the U.S. Data are collected by the member hospitals through medical record abstraction and are submitted to the VON either electronically or through mailing or faxing the paper forms. Hospitals submit data on pregnancy complications, perinatal and postnatal care practices, newborn surgeries, in-hospital mortality, and morbidities. Infants transferred from the birth hospital to another hospital are also tracked for survival status until ultimate disposition or the infant's first birthday.